ALZIRA – RIBERA SALUD

How the Alzira model for integrated care achieves the best outcomes for it’s citizens

What is the Alzira Model? • A model of Integrated Care that started its life in 1993

when a new form of Private an Public Partnership (PPP) contract was agreed for Health Care in Spain

• Ribera Salud was the private company who was

successful in bidding for this contract in the Valencia Region of Alzira

• The contract was to be for a period of 15 years with the

option to extend for a further 5 years • Outcomes have been improving ever since the inception

of the model • Based on population health and payment

The basis of the model There are many parallels between the Alzira health system and the UK health

model, both are free at the point of access and both are fully publically funded. The basis of the model is based on:

Public Financing

• Based on a capitated payment

• The Government pays the provider a fixed and pre-established annual amount for each of its population.

• In Spain in 2015 this was €700 per inhabitant per annum

• This excludes drugs, oxygen therapy and ambulances

Public Property

• The building / health Centre is built on public land and belongs to the government

• The building is built and maintained by the provider

Public Control

• The provider is subject to complying with the established contract and monitored by the commissioner

Private Provision

• The provision (both clinical and non-clinical) is awarded for a pre-established time to a provider

• In the Alzira Model it is for 15 years with the option to extend for a further 5

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• Activity based model

• Contract counts activities and therefore there is an industry to demonstrate every bean has been counted and paid for

• Limited room for innovation as everyone is counting!

• Focuses on the need for more professionals, without

• recognition of other support staff

• development of clinical and non-clinical roles

• Increasing costs with increasing need – doing more of the same, will get you more of the same!

• Does not promote health and prevent ill health and deterioration

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• Commitment to prevention

• Commitment to Health Promotion

• Encourage Innovation and sharing learning

• New buildings

• Money Follows the patient

• Core individual Health Number (SIP) like NHS Number

• “Do what we have to do, in the most appropriate place”

Current Model of Care in England vs Ribera Salud Model

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RESULT: NEED MORE, MORE and MORE…

Core components as reflected by Ribera Salud to make it a success

• To achieve the best health conditions for the citizens

• The contract is designed to deliver 2 core outcomes:

• Highest possible Quality Care and health outcomes

• Value for Money and therefore keeping services in house by ensuring patient loyalty

Capitated Payment

To deliver the outcomes in the contract Ribera Salud have four key principles in delivery which deliver the outcomes defined in the contract and make the shareholders happy. These are: 1. Promoting Health 2. Improving Healthcare Quality 3. Improving Accessibility 4. Improving Efficiency

PPP Model

The whole healthcare network, including the professionals within the provider and the other partners – such as councils, schools, nursing homes etc… all need to have a shared corporate culture! Culture Change is the most important factor, not the hospital!

Networking

There is an absolute focus on Population Health Management!

Healthcare Integration

“Best quality lies in not giving everything and not giving too much... What is best for patient regardless of the price... If it is the best possible option then give it, nothing worse than giving something when they don't need it...”

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Core ideas to consider

• All the Doctors are employed, but incentivised to drive the objectives • Incentives are paid monthly to ALL staff • There is no such thing as failure – if there is a dip in performance a team supports the

doctor to understand the reason for the variation

• Each Primary Care Doctor holds a case load of 1,800 patients at any one time: assigned clinician – continuity is a key

• Primary Care is provided in large health centres with urgent care, some diagnostics

and community care delivered from same centre • Patients can choose with their feet! If a patient leaves Ribera Salud, then Ribera Salud

have to foot the bill at any other provider

• There is no community service, but the community service team members (as we know of in England) are a part of the extended primary care team

• All of this is only possible as the data infrastructure and systems have been fully

embraced • Model focuses on prevention of disease and delay of deterioration to keep costs

down, but increase early detection and innovation

Care

Incentives

Structure

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•Do the correct intervention in the best place with the best quality and efficiency

•Chronic Health Plan

•Proactivity in Care

•Homecare, social and healthcare network

•Patient Safety

•Demand Management

Clinical Management

•Training, Teaching and Research

•Incentives systems aligned to delivery of core outcomes for every staff member

•Career and Professional Development

•Leads to high quality recruitment and retention

•No blame and no failure – support for any that needs it

People Management

•Full Electronic Patient Record

•Support Relationship between doctor and patients (Health Portal)

•Support Relationship between professionals (hospital and primary care)

•Business Intelligence System (including prevention)

•Benchmarking (cost analytics and what-if capabilities)

Information Technology

The success of Ribera Salud

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Level 2: Risk Management

Level 1: Self Care

Level 0: Prevention

Level 3 - Has a team of primary care and specialists around them, strong links with GP and Hospital Team, plus Nurse, Psychologist, Social Worker and whatever else is required. Patients have access to a 24/7 number of a call center run by a nurse. Primary care team immediately notified if patient has been to a specific part of the system and what the outcome was. Patient on Level 3 provides automatic consent!

Level 1 and 2 make up 42.6% of the population - Focus on Self Management and LTC management – Dementia, Hypertension, Diabetes, Obesity, Use of Tobacco and Alcohol Lot of push for patients to use e-tools and Health Portal to self-manage and link with professionals – 35% of population now actively use the Health Portal to stay in touch with their GP Clinical Practice Guides published on the system to support the primary care team, with immediate access via the IT system or phone to specialist support when needed

Level 0 makes up about 57.4% of the population. Prevention Programmes supported by Ribera Salud but targeted by Primary Care Team e.g. Women, Heart, Healthy Eating, Care Givers, Summer (rather than winter awareness campaigns), later life

Kaiser Pyramid of Care

Level 3: Immediate care needs

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Case Management

Good Control

Healthy Population

Opportunities for efficiency

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Cost

Segmentation of patients

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How the IT system is used by a GP Each GP has access to the information on their cohort of patients for which he/she is responsible as well as at a population level. Examples of questions they answer using the IT system include: 1. What is my local population, how have they evolved 2. Age cohorts 3. Male/Female 4. Severity of illness (based on CRGs coding) 5. Where they are 6. Health Status of Diabetes 7. Find out patients who they do not have information for and then send a data list

to the GP to follow up 8. Have a programme to identify patients who do not engage with GPs. The information is usually closer to a function the Public Health Teams in the UK perform, however, this is much more real time and under the responsibility of the GP to monitor and improve…

• Outcomes not activity • “The most appropriate management plan is also the most

efficient” • IT: real time data, shared, risk adjustments • Personal list, continuity • Primary TEAM • Patient pathways include all providers • Home care team • Weekly MDT meetings

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The clinical perspective

Results

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